Herpes Simplex Encephalitis Herpes simplex virus (HSV) is a large DNA virus separated into two

serotypes, HSV-1 and HSV2. HSV-2 is associated with 80 % of genital herpes and HSV-1 with 20 %. The
overall prevalence of genital herpes is increasing and approximately 25 % of pregnant woman have
serological evidence of past HSV-2 infection. Transmission of HSV to the newborn can occur in utero,
peripartum, or postnatally. However, 85 % of neonatal cases are HSV-2 infections acquired during the
time of delivery. The highest risk for perinatal transmission occurs when a mother with no prior HSV-1 or
HSV-2 antibodies acquires either virus in the genital tract within 2 weeks prior

to delivery (first-episode primary infection). Postnatal transmission can occur with HSV-1

through mouth or hand by the mother or other caregiver. Clinical Features. The clinical spectrum of
perinatal HSV infection is considerable. Among symptomatic newborns, one-third has disseminated
disease, one-third has localized involvement of the brain, and one-third has localized involvement of the
eyes, skin, or mouth. Whether infection is disseminated or localized, approximately half of infections
involve the central nervous system. The overall mortality rate is over 60 %, and 50 % of survivors have
permanent neurological impairment. The onset of symptoms may be as early as the fifth day but is
usually in the second week.

A vesicular rash is present in 30 %, usually on the scalp after vertex presentation and on the buttocks
after breech presentation. Conjunctivitis, jaundice, and a bleeding diathesis may be present. The first
symptoms of encephalitis are irritability and seizures. Seizures may be focal or generalized and are
frequently only partially responsive to therapy. Neurological deterioration is progressive and
characterized by coma and quadriparesis. Diagnosis. Culture specimens are collected from cutaneous
vesicles, mouth, nasopharynx, rectum, or CSF. Polymerase chain reaction is the standard for diagnosis
herpes encephalitis. The EEG is always abnormal and shows a periodic pattern of slow waves or spike
discharges. The CSF examination shows a lymphocytic leukocytosis, red blood cells, and an elevated
protein concentration. Management. The best treatment is prevention. Cesarean section should be
strongly considered in all women with active genital herpes infection at term whose membranes are
intact or ruptured for less than 4 hours. Intravenous acyclovir is the drug of choice for all forms of
neonatal HSV disease. The dosage is 60 mg/kg per day divided in 3 doses, given intravenously for 14
days in skin/eye/mouth disease and for 21 days for disseminated disease. All patients with central
nervous system (CNS) HSV involvement should undergo a repeat lumbar puncture at the end of
intravenous acyclovir therapy to determine that the CSF is polymerase chain reaction (PCR) negative and
normalized. Therapy continues until documenting a negative PCR. Acute renal failure is the most
significant adverse effect of parenteral acyclovir. Mortality remains 50 % or greater in newborns with
disseminated disease.